WASHINGTON — Maximizing efforts to vaccinate children at the 18-month well-child visit would dramatically increase the proportion of children who are up to date, Richard A. Schieber, M.D., said at the annual meeting of the American Academy of Pediatrics.
Specifically, if office-based systemic chart reviews and reminder/recall systems, community outreach programs, and individual case management all were focused on bringing children in for immunizations during their 18th month of life, the proportions of those up to date would more than double—from the current 57% up to 87%—for the 4:3:1:3:3:1 series, which includes diphtheria-tetanus-acellular pertussis, poliovirus, measles-mumps-rubella, Haemophilus influenzae type b, hepatitis B, and varicella.
“We're really talking about tailoring an approach to raise consciousness among health care providers,” said Dr. Schieber, senior adviser for influenza at the Centers for Disease Control and Prevention's coordinating center for infectious diseases, Atlanta.
A previous CDC study using data from the 1999 National Immunization Survey found that among children who were not up to date for the 4:3:1:3:3 series (all of those listed above except varicella), 74% needed only one more visit to complete the series, and of those, 62% needed just one more shot.
The authors concluded that if all children who needed one more visit were to receive it, the national coverage for all recommended vaccinations among children aged 19–35 months would be 93%, thus exceeding the 90% Healthy People 2010 goal (Am. J. Prev. Med. 2001;20(suppl.):32–40).
In a follow-up to that study using data from the 2003 National Immunization Survey, a simulated birth cohort of children turning 19 months old was used, comprising 59% white, 14% black, 21% Hispanic, and 6% children of other races.
The simulated dosing rules stated that no multiple administrations of the same antigen would be given.
At prebaseline (the day the child turned 18 months), just 40% were up to date with the 4:3:1:3:3:1 series. If nothing changed after that, 57% would be up to date by the day they turned 19 months.
By 24 months, the proportion would increase to 67%. However, if every child made a visit at age 18 months and received all needed shots (up to four injections) at that time, 87% would be up to date by the day they turned 19 months of age, Dr. Schieber said.
Of the total 43% not up to date by 19 months, 71% needed just one more visit and of those, 44% needed just one more vaccination. Based on U.S. census data, that 71% translates to about 1.2 million children. “That's not a small number of children we'd be affecting by not doing much more than awareness raising among health care providers,” he noted.
The most common vaccinations the children lacked were DTP/DTaP (57%) and varicella (26%). Such a focused program would work for all races, bringing the coverage rates up from 60% to 89% among whites, from 48% to 82% in blacks, and from 56% to 86% among Hispanics. As simulated, all states would achieve at least 80% up-to-date coverage, and 13 states would achieve at least 90%.
Ongoing analysis of the series to include the conjugate pneumococcal vaccine has been hampered by shortages over the last couple of years, but preliminary data suggest that the proportion of children up to date by 19 months would rise from the current 30% to 72% if such a program were implemented. “That's really dramatic,” Dr. Schieber remarked.
Field trials would be needed to back up the real world effectiveness of this approach. None are currently planned, although “we are entering a new budget year, so it is possible that funding for this might become available,” he told FAMILY PRACTICE NEWS.